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Based on observation, interview and record review the Hospital failed to ensure the Director of Dietary supervised and maintained the dietary department in a responsible manner in that 1) Cleanliness issues were observed in the retail and kitchen production areas, 2) Lack of labeling of food items in the kitchen retail and production areas was observed.

Findings included:


1) Cleanliness issues were observed in the retail and kitchen production areas.
On 04/17/13 from 08:35 AM to 10:05 AM observation rounds were conducted in the dietary department with Personnel #4 and Personnel #10.

a) Kitchen Retail area:
The dining area built in cabinets had two cabinet doors with split/exposed particle board. The cabinet doors were not sanitizable.
A high-chair sitting in the dining area had brown stains on the front of the chair and on the foot rest.
The fork dispenser in the dining area was observed with brown stains and needed cleaning.
Behind the serving line the metal counter contained two soup dispensers (not in use at the time of this observation). The counter was soiled with a white substance smeared on the surface of the counter.
Behind the serving line on a lower metal shelf was a plastic bin which contained 9 small individual containers of cereal. The interior/exterior surface of the bin was soiled/dirty and had a collection of debris inside the bin. The metal shelf was soiled with debris scattered on the surface.
A second plastic bin had a large plastic bag of individually wrapped candy. The plastic bag was torn, soiled with brown stains. The interior/exterior surface of the bin was soiled with a collection of debris.
A large green bowl was observed on top of a shelf on the serving line. The interior surface of the bowl was soiled and contained unwrapped pieces of candy.
Behind the serving line on the counter was a clipboard with food temperatures. The clipboard was soiled/dirty with brown stains and smears on the plastic and metal surface of the clipboard.
A step stool was observed on the floor next to the wall. The step stool was soiled with debris and dirt. On top of the step stool was a plastic bag with Styrofoam food containers available for use.
A three shelf roller cart behind the serving line was soiled with debris. The second shelf of the cart had a red container of sanitizer solution for cleaning. A plastic bag of bagels and a loaf of raisin bread was stored next to the solution.
The floors, walls and baseboards, behind the serving line were soiled with debris. The door leading into the kitchen was soiled and dirty.

b) Kitchen Production area:
The dietary ice maker lid gasket was torn and peeling away from the interior surface of the lid. The exterior surface of the filter had a collection of dust and required cleaning.
The inpatient tray lid rack shelf' (holds lids for trays) was soiled and littered with debris.
The exterior surface of the wall next to walk-in refrigerator and freezer had peeling paint and the surface was not sanitizable.
A metal work station contained 5 drawers for storage. Two of the five drawers had debris in the drawer and the interior lip of the drawer was stained with a brown substance.
Clean pots and pans were stored on a large three shelf rack. Eight large pans were stacked wet on top of each other. Personnel #10 stated the pans should not have been put away wet.
Five plastic bins contained, rice, flour, powdered sugar and cornmeal. The lids of the bins were greasy, soiled with brown particles. The exterior surface of the bins were soiled and needed cleaning.
A food weight scale was soiled with debris. The exterior surface of the scale was rusted.
Two bags of ziti pasta and one bag of bowtie pasta was observed on top of the garbage disposal. Personnel #10 stated food items were not supposed to be on top of the disposal. The two compartment sink had soiled items which included a soiled cloth, spoon and a bucket of sanitizer solution. On the ledge connected to the two compartment sink was a large metal bowl with olives and tomatoes and an opened can of artichoke hearts. Personnel #10 was asked if the above area was a designated food preparation area. Personnel #10 stated "No." Personnel #10 informed the staff to discard the pasta and the food items. Personnel #10 verified and acknowledged all the above surveyor observations.

2) Lack of labeling of food items was noted in the kitchen retail and production areas.

a) Kitchen Retail Area:
The serving line had 17 bagels and 22 pieces of bread available for consumption. The individual items were not labeled when opened.
The refrigerator unit next to the grill contained a metal container of lettuce, tomatoes and onions. The food products were not labeled. Personnel #10 stated the items should be labeled. Personnel #10 stated the items were not consumable due to the items having freezer burn.

b) Kitchen Production Area refrigerator:
Brussels sprouts, onions and bacon were observed opened and not labeled. Additionally salad bar containers of black olives, green olives, cheese, ham, chicken, lettuce, tomatoes and onions were not labeled when prepared. Personnel #10 verified the above surveyor observations.

The Director of Nutritional Services Job Description dated 02/22/13 reflected, "Responsible for the storage and preparation of food supplies, maintenance of equipment and proper sanitation of work areas...director ensures proper assembly, service of foods, sanitation and safety of service and utility areas of the department."

The policy entitled, "Food Storage" dated 01/2011 reflected, "To ensure safe and sanitary storage of...dry goods and food...chemicals are stored separately from food and dry goods...all items must be dated..."

The policy entitled, "Food safety" dated 01/2011 reflected, "To prevent the possibility of food borne illness...food is protected against contamination from dust, vermin, unclean utensils, unclean work surfaces..."

Based on observation, interview and record review the infection control officer failed to provide a system to identify, report, investigate, control and avoid sources and transmission of infections and communicable diseases in the maintenance of a sanitary hospital environment in that
1) Dusty patient care equipment was found in the hospital's Emergency Department. Clean and contaminated equipment was stored in close proximity.
2) Cleanliness issues were observed in the retail and kitchen production areas, and
3) Equipment ready for patient use was observed on the floor in patient care areas.

Findings included:

1) On 04/16/13 between 10:00 AM and 10:39 AM observational rounds were conducted in the hospital's Emergency Department (ED) with Personnel #2, Personnel #5, Personnel #6, and Personnel #7.
The crash cart, the EKG machine, and the ortho cart next to the bay area were dusty with white particles.
Three plastic bins filled with KY jelly, cotton tip applicators, and tongue depressors in the ED's clean utility room were dusty. Adult briefs and baby diapers were observed in dusty bins. Blood pressure cuffs were observed in three dusty blue bins on top of a gray cart.
The environmental storage room had a dust mop next to a white bin with clean wash rags. Personnel #7 stated, "The mop is dirty" and agreed clean and dirty equipment were stored within close proximity.
The triage area had two dusty shelves. A cart underneath the scale had multiple unwrapped baby diapers. Hospital Personnel #2 stated the diapers were "supposed to be individually wrapped."
Hospital Personnel #5 and Personnel #6 verified and acknowledged all of the above surveyor observations.

2) On 04/17/13 from 08:35 AM to 10:05 AM observation rounds were conducted in the dietary department with Personnel #4 and Personnel #10.
Cleanliness issues were observed in the retail and kitchen production areas.

a) Kitchen Retail Area:
The dining area built in cabinets had two cabinet doors with split/exposed particle board. The cabinet doors were not sanitizable.
A high-chair sitting in the dining area had brown stains on the front of the chair and on the foot rest.
The fork dispenser in the dining area was observed with brown stains and needed cleaning.
Behind the serving line the metal counter contained two soup dispensers (not in use at the time of this observation). The counter was soiled with a white substance smeared on the surface of the counter.
Behind the serving line on a lower metal shelf was a plastic bin which contained 9 small individual containers of cereal. The interior/exterior surface of the bin was soiled/dirty and had a collection of debris inside the bin. The metal shelf was soiled with debris scattered on the surface.
A second plastic bin had a large plastic bag of individually wrapped candy. The plastic bag was torn, soiled with brown stains. The interior/exterior surface of the bin was soiled with a collection of debris.
A large green bowl was observed on top of a shelf on the serving line. The interior surface of the bowl was soiled and contained unwrapped pieces of candy.
Behind the serving line on the counter was a clipboard with food temperatures. The clipboard was soiled/dirty with brown stains and smears on the plastic and metal surface of the clipboard.
A step stool was observed on the floor next to the wall. The step stool was soiled with debris and dirt. On top of the step stool was a plastic bag with Styrofoam food containers available for use.
A three shelf roller cart behind the serving line was soiled with debris. The second shelf of the cart had a red container of sanitizer solution for cleaning. A plastic bag of bagels and a loaf of raisin bread were stored next to the solution.
The floors, walls and baseboards, behind the serving line were soiled with debris. The door leading into the kitchen was soiled and dirty.

b) Kitchen Production area:
The dietary ice maker lid gasket was torn and peeling away from the interior surface of the lid. The exterior surface of the filter had a collection of dust and required cleaning.
The inpatient tray lid rack shelf' (holds lids for trays) was soiled and littered with debris.
The exterior surface of the wall next to walk-in refrigerator and freezer had peeling paint and the surface was not sanitizable.
A metal work station contained 5 drawers for storage. Two of the five drawers had debris in the drawer and the interior lip of the drawer was stained with a brown substance.
Clean pots and pans were stored on a large three shelf rack. Eight large pans were stacked wet on top of each other. Personnel #10 stated the pans should not have been put away wet.
Five plastic bins contained, rice, flour, powdered sugar and cornmeal. The lids of the bins were greasy, soiled with brown particles. The exterior surface of the bins were soiled and needed cleaning.
A food weight scale was soiled with debris. The exterior surface of the scale was rusted.
Two bags of ziti pasta and one bag of bowtie pasta were observed on top of the garbage disposal. Personnel #10 stated food items were not supposed to be on top of the disposal. The two compartment sink had soiled items which included a soiled cloth, spoon and a bucket of sanitizer solution. On the ledge connected to the two compartment sink was a large metal bowl with olives and tomatoes and an opened can of artichoke hearts. Personnel #10 was asked if the above area was a designated food preparation area. Personnel #10 stated "No." Personnel #10 informed the staff to discard the pasta and the food items. Personnel #10 verified and acknowledged all the above surveyor observations.

The Director of Nutritional Services Job Description dated 02/22/13 reflected, "Responsible for the storage and preparation of food supplies, maintenance of equipment and proper sanitation of work areas...director ensures proper assembly, service of foods, sanitation and safety of service and utility areas of the department."

The policy entitled, "Food Storage" dated 01/2011 reflected, "To ensure safe and sanitary storage of...dry goods and food...chemicals are stored separately from food and dry goods...all items must be dated..."

The policy entitled, "Food safety" dated 01/2011 reflected, "To prevent the possibility of food borne illness...food is protected against contamination from dust, vermin, unclean utensils, unclean work surfaces..."

The policy entitled, "Sanitation & Maintenance of Equipment" with a review date of 01/2011 reflected, "To ensure safe work practices in order to provide uncontaminated products and a safe work environment..."

3) Patient #27 was observed on 04/17/13 at 11:59 AM in the hospital's second floor patient care area. A rectangular pink basin with sudsy water was observed on an overhead table. Patient #27 stated he used it for shaving "2-3 hours ago."

Sleeves of the sequential compression device (SCD), a device to prevent patients from having blood clots, were on the floor in three patient rooms (Patient #3, Patient #25, and Patient #27) as observed on 04/17/13 between 11:40 AM and 12 noon.
Hospital Personnel #11 acknowledged and verified the above findings.

Review of Hospital Policy #6001 revisioned on 02/13/13 reflected "all equipment should be cleaned with hospital approved disinfectant solution when visibly soiled."